Integrating CCSVI into a busy ambulatory practice
[SO THAT'S DR SULLIVAN! I HADN'T SEEN HIM BEFORE.]
Credentialing is probably already in place
[CREDENTIALING IS THE PROCESS OF GETTING INSURANCE TO RECOGNISE YOU AS A PROVIDER WHO THEY WILL PAY.]
Affiliations: many capable, well-respected interventionalists have been prevented from performing CCSVI procedures because of their hospital affiliation.
[DR. DAKE. DR. MCDONALD. WHO WAS THE DOCTOR WHO HAD A PATIENT PREPPED TO GO, WHO WAS TOLD RIGHT THEN THAT HE COULD NOT DO ANY MORE? THIS WAS ALL LATE 2009 AND THEN EARLY-MID 2010. I THINK WE ARE PAST ALL THAT NOW….]
Free-standing center will still have some issues. Neurologists will be opposed. Patients will come to you with very different views. They are convinced this works and do not want to wait for trials which could take years. Messages online can get personal and negative. If you get involved in this and treat these patients, you may be the target of this as well.
[A GOOD REASON FOR ALL OF US ONLINE TO TAKE A LOOK AT OUR OWN WORDS AND MAKE SURE WE HAVE BEEN RESPECTFUL.]
Dr. Sullivan advises that the IR take a balanced perspective during the informed consent. Take time to answer questions in detail about what is known and not known. Don't promise more than can be delivered.
[OMG. DO YOU REMEMBER BLUESKY ASKING A CLINIC, EARLY ON, IF THEY HAD HANDICAPPED ACCESSIBILITY OR GUEST WHEELCHAIRS, I CAN'T REMEMBER WHAT EXACTLY, AND SHE WAS TOLD IT DIDN'T MATTER, SHE WOULDN'T NEED IT AFTERWARDS!! TALK ABOUT PROMISES. IT BREAKS MY HEART THAT THIS WAS EVER SAID.]
Tell patients that we are in the early stages of the understanding of this treatment.
[THIS IS ALL VERY PRACTICAL. SO FAR I LIKE DR. SULLIVAN.]
If possible, add to knowledge. Become part of a registry.
[VERY IMPORTANT! DO NOT LET THE DATA GO UNUSED.]
Be aware that there is a learning curve.
[I THINK THIS IS EXTREMELY SIGNIFICANT AS PATIENTS. A DOCTORS DOING HIS 1ST PATIENT IS NOT AS GOOD AT IT AS DOCTORS DOING THEIR 100TH PATIENT. LEARNING CURVE. THERE MIGHT BE LIFELONG CONSEQUENCES FOR THAT 1ST PATIENT THAT THE 100TH PATIENT DODGED. CHOOSE YOUR IR WISELY.]
Dr. Sullivan talks about the learning curve specific to CCSVI. How to diagnose. He encourages getting ultrasound or MR prior to procedure. Learn the symptoms of CCSVI, in order to assess if you've had a good result. Learn the angiographic findings, such as what and how to treat, in order to direct your therapy. Learn how to prevent or manage complications. Learn what to do for follow-up.
[THE ANGIOGRAPHIC FINDINGS, INCLUDING WHAT AND HOW TO TREAT, IS APPROACHED DIFFERENTLY BY DIFFERENT PROVIDERS, AND BY A PROVIDER IN THE EARLY STAGES OF BEGINNING TO TREAT CCSVI AND LATER ON WHEN HE HAS SEEN AND DONE MORE. LEARNING CURVE, DEFINITELY.]
This is an evolving field. Find a mentor if you can who is doing these in large volume. The internet can be a good source of information to both find out what the patients are thinking and also physicians are involved in some of these sites and you can learn from some very experienced physicians on these sites.
[LOOK AT THAT! HE LISTS THE TiMS WEBSITE AND CCSVI LOCATOR.]
You'll be asked how to integrate ccsvi treatment into ongoing therapy. You'll decide how to interact with neurologists. I tell patients it's up to them. Most patients say they are not going to tell their neurologists, that their neurologists are opposed, and that they will tell their neurologists after they have it done. Patients are on disease-modifying drug or alternative therapies.
Coding and billing: up until recently insurance uniformly paying. Just recently BCBS has stated that CCSVI is not medically necessary to be treated. What's important is the state the patient lives in, not the state you're practicing in.
[I THOUGHT IT WAS BOTH. HE ALSO LISTS BCBS MN AS ONE OF THE STATES WITH POLICIES AGAINST CCSVI BUT AS FAR AS I AM AWARE MN IS STILL GOOD. I WILL CHECK ON THAT.]
You'll have to decide on what to do about rejections. Appeal? Give the patients the code and have them do the appeal or have the office appeal? Determine cash charge for patients without insurance.
He lists the specific billing codes, if anyone is interested in those, for things like transluminal balloon angioplasty, placement of a stent, etc. None of the codes are specific to CCSVI.
Building a practice: you won't get referrals from neurologists. [lol!! Although he says he does get some but not many.] You can get involved in the online sites. [!] You can establish a diagnostic component to your practice. Direct patient marketing is also an option.
[WHILE DIRECT PATIENT MARKETING IS BEING DONE, SUCH AS ADVERTISEMENTS THAT STARTED POPPING UP ON FACEBOOK, IT IS QUESTIONABLE TO ME THAT THIS IS A PROCEDURE I WANT MARKETED TO PATIENTS AT THIS EARLY STAGE IN THE DISCOVERY.]
Patient evaluation involves reviewing the doppler, do a careful review of signs and symptoms, obtain history, answer questions, discuss treatment options.
You'll need to determine if you'll treat patients with CCSVI without MS. Determine if you're prepared to treat children. Can you handle complications and problems if you treat children in an outpatient ambulatory setting, without the back-up specialists at a hospital?
[SHOULD PATIENTS WITH CCSVI WITHOUT MS BE TREATED? SHOULD CHILDREN BE TREATED?]
Procedure: schedule as 2.5 hours when you start. Full anticoagulation during procedure, supine for four hours, no problems with hematomas. Nursing staff for recovery. Minimal post-procedure pain in these patients. Equipment: you need to be prepared for taller patients, which means exchange length guidewires, balloons on 120 cm shafts, and 90 cm diagnostic catheters. You can get by on smaller ones but don't want to be caught offguard when the longer ones are needed.
Followup: Distance, difficulty of travel for these patients may limit follow-up. He does telephone follow-up and email and visits based on symptoms. Email is an excellent means for procedure-based practice to provide detailed communication between MD and patient. He adds the email exchange to the patients' charts. To my patients if you view this online [OR READ CECE'S NOTES], if you haven't sent me an email, please do. It's really how we learn.
In an ideal world, he would get routine follow-up with ultrasound but doesn't know exactly what intervals it should be. With patients coming from a distance, it is difficult to have centers that can do these properly.
Mail order pharmacy can ship lovenox to patients' home.
Conclusions: you probably have the necessary skills if you're performing endovascular procedures but need to learn details related to CCSVI. You need to be comfortable with CCSVI controversy and some of the political or insurance barriers.
[MY CONCLUSION: WHILE IT IT BENEFICIAL TO PATIENTS TO HAVE LOCAL IR'S GETTING INTO CCSVI TREATMENT, THERE IS MUCH TO BE SAID FOR GOING WITH THE EXPERT OPTION, NOT THE LOCAL OPTION, WHEN THE EXPERT HAS GREATER EXPERIENCE. ANY IR'S INSPIRED BY THIS TALK TO GET INTO CCVSI WILL HAVE TO START UP THAT LEARNING CURVE. IN THE BEGINNING THEY DO NOT EVEN KNOW WHAT THEY DO NOT KNOW AND IT IS THE PATIENT THAT INCURS ANY DAMAGE THAT MIGHT HAVE BEEN PREVENTABLE WITH EXPERIENCE. I CANNOT REMEMBER WHICH IR IT WAS, BUT IT HAS BEEN SAID THAT CCSVI WAS THE MOST DIFFICULT LESIONS THEY HAD TREATED. IT IS A COMPLEX DISEASE THAT PRESENTS IN VARIABLE WAYS, IT IS NOT ALWAYS VALVES, ALTHOUGH IT IS OFTEN VALVES. THE JUGULARS ARE MORE FRAGILE THAN INITIALLY THOUGHT, WHEN THE OVERSIZED BALLOONS WERE BEING USED. AND IVUS WAS NOT MENTIONED AT ALL IN DR. SULLIVAN'S TALK. HE IS NOT EVEN SUGGESTING THAT NEWBIE IR'S PURCHASE AN IVUS BEFORE STARTING TO TREAT CCSVI, DESPITE THE UNDISPUTED VALUE OF IVUS IN INTERROGATING INTRALUMINAL ABNORMALITIES.]
[GREAT PRESENTATION BY DR. SULLIVAN. IF YOU'RE HIS PATIENT, SEND HIM AN EMAIL, LET HIM KNOW HOW YOU'RE DOING, OK?]